2301 South 15 Street, Omaha, NE 68108 (402) 502-9224
Dear potential resident
Thank you for contacting us. An application form is enclosed. When we get to meet, I will give you a resident handbook that hopefully you will read. Of course, we do have a structured environment and encourage our residents to be working on education or continuing on a job if they have one.
We include the program on Healing the Culture (The 4 Levels of Happiness) and Earn While You Learn (a parenting program). We are adapting our programs and policies from other maternity homes and are adjusting them as needed.
Many businesses and volunteers have done much to make sure the building is comfortable and home-like. We will do our best to help each resident adjust and find a path in life that suits her. There are many community resources we can utilize. One of the first items of importance is to get you on housing lists. We utilize professional pregnancy counselors from several agencies to help sort through the many decisions each mom will encounter. The avenues of parenting and adoption will be presented but the decision is solely that of the mother.
Although we are Catholic based, we welcome women from any or no religion. I briefly explain our traditions and encourage all our residents to be involved in religious services somewhere each weekend.
I look forward to meeting you. When the application is returned, I will send you a questionnaire and a separate one to each of the three references that you list. We do ask for a $350 damage deposit that will be returned when you finish the program and leave - around 6 weeks after the birth of your baby. However, if there is financial difficulty, we can work around it.
Praying for you
PERSONAL Name:_________________________________________________________________________Date:______________ Current Address:_________________________________________________________________________________ Birth date:_______Phone:_______________________________ Social Security No.:_____________________ Department of Public Assistance ("DPA") Caseworker:______________________________________________ DPA Number:_______________Phone No:_______________________ Do you have any other caseworker or counselor?_________If so, list:______________________________ Name:____________________Agency:_________________________________________________________________ Address:_________________________________________________________________________________________ Current Income: $________________ mo.____________Source:_________________________________________ Do you have any physical or medical conditions that limit your activities?______Yes_____No If so, specify: What are your favorite activities or hobbies? EDUCATION/VOCATION Present or last high school attended:____________________________________________________________ Address:_________________________________________________________________________________________ Dates attended:_________________________________________ Last grade completed:___________________ If you have dropped out of school: Age when you left:___________ Last grade completed: ___________________ Reason for dropping out: ________________________________________________________________________ Have you received any schooling other than high school? ________ Yes ___________ No If so, name of institution:______________________________________________________________________ Course of study: ______________________________Dates attended:___________________________ YOUR LIVING SITUATION List the people currently living in your household: Persons you have been living with if other than your parents: Name: _________________________________________________ Phone: __________________________________ Address: PARENTS Father's name: ________________________________ Mother's Name: __________________________________ Address: ______________________________________ Address: ________________________________________ Phone: Home (_____)___________________________ Phone: Home (____) ______________________________ Work: _________________________________________ Work:____________________________________________ Employer:______________________________________ Employer: _______________________________________ Are your natural parents (check appropriate box): _____ married and living together _____ separated _____ married not living together _____ divorced _____ deceased (which parent? ____________________) If your natural parents are not living together, how long have they been apart?__________________ Have either of your parents: _____ remarried? (complete below) _____ lived with another partner? Stepfather's name: _____________________________________________________ Stepmother's name: _____________________________________________________ BROTHERS AND SISTERS (including step and half) Name Age Sex Address ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ What are you doing now? ____ school ____ training program ____ job _____ other (specify) Name of school or employer: _______________________________________________________________________ Address: __________________________________________________________________________________________ Course of study or position: ______________________________________________________________________ Do you plan to continue your education or receive any more training at the present time? ________ yes ________ no ________ don't know I plan to study __________________________________________ at ____________________________________ What is your educational goal? What is your vocational goal? YOUR CHILD(REN) (Fill out only if applicable) Name: _________________________________________________________ Birth date: Social Security No.: __________________________________________ DPA No. __________________________ CHILD CARE Who will be caring for your child(ren) while you are a resident at WCCH? Name: Phone: Address: __________________________________________________________________________________________________ RELIGIOUS BACKGROUND From what religious background do you come?_______________________________________________________ Are you currently attending church? _____ Yes _____ No What is the name of the church? __________________________________________________________________ If you are not currently attending church, what religious or denominational preference would you have? Why are you interested in moving into our household? How did you find out about our program? What things about yourself do you want to change or improve? Do you realize this will be a structured environment including educational, parenting, and Life skills goals? _______Yes _______NO _____________________________________________ Applicant Signature Dated: ________________________________________ REFERENCES List three people who know you well. You may name one relative. Please include your social worker or school counselor if they have worked with you in the past two years. Give complete mailing addresses. 1. Name:______________________________________ Phone: _______________ Address:_____________________________________________________________ City, State, Zip:________________________________________________________ How do you know them? 2. Name:______________________________________ Phone: _______________ Address: _____________________________________________________________ City, State, Zip: _______________________________________________________ How do you know them? 3. Name: _____________________________________ Phone: ________________ Address: ______________________________________________________________ City, State, Zip: _________________________________________________________ How do you know them?
Your name:________________________________________________________________Age:_________ Your Child(ren) name(s) and age(s): ___________________________________________________________ _______________________________________________________________________________________________ Current address where you receive mail: Street or box number:_____________________________________________________________________ City___________________________ State:_________Zip:________________ Phone number where you can-be reached during the day: ( ) _____________________ FAMILY Please write a paragraph concerning your relationship with your parents. Please write a paragraph concerning your relationship with your brothers and sisters. CHILD'S FATHER Please give the full name and the age of the father of the baby: How did he feel about the pregnancy and what are his feelings now? What is your relationship with him at the present time? Does he know you are thinking about coming to our home? Yes No RELIGIOUS How active have you been in church, if at all ? What are your general feelings about religion and God? Please write a paragraph. MEDICAL Please list any previous pregnancies and describe what happened: Include the due date and, if you had an abortion, when that occurred. Please give a list of all the drugs you have used, how often you used them and the last time that you had them. Why did you decide to try to take drugs? If you have quit taking them, why did you decide to stop? Please write a paragraph about your use of alcohol. Include how often you drank and the last time you had a drink. When you drink, do you drink to get drunk and if so, why? What made you decide to use alcohol? If you have quit using alcohol, what made you decide to quit? Why do you want to come here ? What are some things about yourself that you would like to change or improve? What are some goals you have for yourself and your child? 1._______________________________________________________________________________________ 2._______________________________________________________________________________________ 3._______________________________________________________________________________________ 4._______________________________________________________________________________________